Nokea
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.
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Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
- A. Insomnia
- B. Agnosia
- C. Aphraxia
- D. Aphasia
Correct Answer: D
Rationale: The correct answer is D: Aphasia. Mr. Dela Isla's inability to comprehend what the nurse was saying indicates a language impairment, which is characteristic of aphasia. Aphasia is a condition that affects a person's ability to understand or produce language due to damage to the brain's language centers. Insomnia (A) is a sleep disorder, Agnosia (B) is a perception disorder, and Apraxia (C) is a motor planning disorder, none of which align with Mr. Dela Isla's symptoms.
Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
- A. For its synergestic effect
- B. Because of the client's resistance to
- C. To rule out cholinergic crisis Neostigmine
- D. To confirm the diagnosis of myasthenia
Correct Answer: C
Rationale: The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms.
Incorrect choices:
A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine.
B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H
The normal life expectancy for 50% of patients ith amyotropic lateral sclerosis (ALS) is:
- A. 3 years
- B. 10 years
- C. 5 years
- D. 20 years
Correct Answer: C
Rationale: The correct answer is C (5 years) because ALS is a progressive and fatal neurodegenerative disease. The median life expectancy for most ALS patients is around 3-5 years from the onset of symptoms. Choice A (3 years) is too short for 50% of patients. Choice B (10 years) and Choice D (20 years) are longer than the typical life expectancy for ALS patients, making them incorrect. The progression of ALS varies among individuals, but statistically, 50% of patients would be expected to live around 5 years after diagnosis.
A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: 'Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?
- A. Disturbed thought processes
- B. Related to
- C. Alzheimer’s disease
- D. Incoherent language
Correct Answer: A
Rationale: The correct answer is A: "Disturbed thought processes." This is the problem statement because it identifies the client's main issue, which is the disturbance in their thought processes. The "related to" part (B) indicates the cause, "Alzheimer's disease" (C) is the etiology, and "incoherent language" (D) is the evidence. By focusing on the problem statement, the nurse can develop appropriate interventions to address the client's disturbed thought processes.
Why must a nurse measure the intake and output and recommend a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis?
- A. To determine the clients response to the therapy
- B. To flush out the infectious microorganisms from the urinary tract
- C. To determine the location of discomfort
- D. To detect any evidence of changes
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Measuring intake and output and recommending increased fluid intake for a client with pyelonephritis is crucial to help flush out infectious microorganisms from the urinary tract. By increasing fluid intake, the client will urinate more frequently, aiding in the removal of bacteria causing the infection. This helps in reducing the bacterial load in the urinary tract and promoting faster recovery. Monitoring intake and output also helps ensure the client is adequately hydrated.
Summary of Other Choices:
A: Monitoring intake and output is more about assessing hydration status and kidney function rather than the response to therapy.
C: Intake and output measurement does not directly determine the location of discomfort in pyelonephritis.
D: Monitoring intake and output is not primarily for detecting changes but for ensuring proper fluid balance and aiding in infection clearance.